THE DISCOVERY OF
THE PHYSIOLOGICAL METHOD
I
OF INDUCING RESPIRATION IN CASES OF
APPARENT DEATH FROM
DROWNING, CHLOROFORM,
STILL-BIRTH, NOXIOUS GASES,
ETC., ETC.
I
HENRY R, SILVESTER, B.A., M.D., Lond,
I
CLAPHAM COMMON, S.
ASSOCIATE OF KING’S COLLEGE, LONDON ; AND FORMERLY SCHOLAR IN
HUMAN AND COMPARATIVE ANATOMY IN THE ROYAL COLLEGE '
OF SURGEONS OF ENGLAND. X «’
AUTHOR OF “ THE PHYSIOLOGICAL METHOD OF TREATING INCIPIENT GO NSUBiPTjtON
WITH DIRECTIONS FOR ITS PREVENTION.” / .( ^
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LONDON: '-v.
JOHN CHURCHILL & SONS, NEW BURLINGTON STREET.
Death may usurp on Nature many hours.
And yet the fire of life kindle again
The overpressed spirits. I have heard
Of an Egyptian had nine hours lien dead.
By good appliance was recovered.”
Shakespere, Pericles , act
[ The right of Translation is reserved .]
PEEFACE.
The demand for a third edition of this work affords me
an early opportunity of remarking that the principles ad-
vocated in the following pages have been introduced into
the Army and the Navy under the sanction of His Royal
Highness the Duke of Cambridge, and His Grace the
Duke of Somerset,* respectively. They have likewise
been adopted by the Government Emigration Board ; and,
at the recommendation of the Royal Medical and Chivur-
gical Societ}r, they have been made the foundation of the
New Regulations of the Royal Humane Society. The
Committee of the Royal Medical Chirurgical Society,
consisting of the following gentlemen,
Charles J. B. Williams, M.D., F.R.S.
C. E. Brown-Sequard, M.D., F.R.S.
George Harley, M.D.
* A large portion of the second edition was ordered by the
Admiralty with a view to a copy being furnished to each of Her
Majesty's ships in commission .
PREFACE.
W. S. Kirkes, M.D.
H. Hyde Salter, M.D., F.R.S.
J. B. Sanderson, M.D.
W. S. Savory, F.R.S.
E, H. SlEVEKING, M.D.
after laborous experimental investigation, published their
report entirely favourable to the method advocated by me,
as will be seen further on. Two letters have been in-
serted and will be read with interest as the recorded
opinion of the late eminent Surgeon, Sir Benjamin C.
Brodie, Bart., F.R.S.
“ Lateat scintillula forsan.’
A NEW METHOD OF RESTORING RESPIRA-
TION TO PERSONS APPARENTLY DEAD
FROM SUSPENDED BREATHING.
The subject of this work is one of deep practical and
physiological importance, and is of direct personal interest
to every individual, since no one can claim for himself
or his family security from the dangers against which this
method proposes a remedy.
In the following pages, I purpose to describe a new
method of treating apncea, or suspended respiration, by
inducing such movements of the thoracic parietes
through the muscles of respiration, as shall cause the
atmospheric air we breathe to be drawn into and again
expelled from the lungs of the asphyxiated person — and
without having recourse to the employment of any me-
chanical apparatus. The process is of universal applica-
tion ; it is easy of performance, entirely in harmony with
that of Nature, and does not prevent nor interfere with
the use of those means in which much confidence has
hitherto been placed; such, for instance, as the use of
the warm bath and other plans of restoring warmth and
circulation.
Apncea, or suspended respiration, may be the result of
drowning, of still-birth, of suffocation, of strangling, of
hanging, of garotting, of epilepsy, of apoplexy, of the
undue or excessive employment of opium, of chloroform,
of certain gases, etc.
The methods usually resorted to for restoring persons
affected by suspended respiration may be grouped under
three divisions. The first division includes various plans
for exciting the reflex function of the nervous system.
The second provides for the maintenance of warmth and
circulation. The third proposes means for supplying air
to the lungs, either by mechanically forcing air into the
chest, or by inducing such movements in the thoracic
parietes, as shall induce fresh air to enter into the pectoral
cavity alternately with the expulsion of the products of
respiration.
6
It is with the third divison that we are especially con-
cerned.
With regard, however, to the second division — the
treatment by warmth and friction only — I may be allowed
to make a few passing observations. There is much dif-
ference of opinion, but it must be said that experience is
greatly in its favour; greater numbers having been restored
by it than by any other means. It is to be kept in mind
that persons are usually submerged in cold water, and the
chief point aimed at is the restoration and maintenance of
the natural temperature of the body, so that pulsation
may be increased, and thus respiration encouraged with
more hope of success. Hence the Royal Humane Society,
in its printed rules, particularly recommended it as a re-
storative in cases of the apparently drowned, and of the
apparently dead, from intense cold, or from hanging.
“ In one of the most remarkable cases of resuscitation on
record, the individual had been fourteen minutes under
water, and no signs of returning animation were evinced
until the treatment, which consisted simply in the appli-
cation of warmth and constant friction, had been persisted
in for eight hours and a half from the time of the acci-
dent.” (Taylor, Med . Jurisp .)
Edwards, Brown-Sequard, Dr. Marshall Hall, and
others, have experimented on animals. But the results of
experiments on animals are unsatisfactory, and would not,
probably, be applicable to man. “ The practical conclu-
sion at which Dr. Hall arrived was, that, in the treatment
of apnoea, the continuous warm bath must be excluded.
This inference is, we think, scarcely warranted by the
facts. In the experiments he made, animals were com-
pletely submerged in warm water, so that there was no
escape for the products of respiration ; whereas, in the use
of the warm bath, there would not be this obstacle.”
(. British and Foreign Med.-Cliir . Review , 1858.) “The
duration of life in asphyxia seems to be in proportion,
not to the warmth, but to the maintenance of a medium
temperature of the patient or of the animal made the
subject of experiment. The restoration of warmth can
only be safely effected when the respiratory movements
are maintained, and the circulation is promoted. The
warm bath, used alone , appears to have been often fatal.”
La ncet, December 1856.)
7
* Dr. Edward Smith states that the hot water bath
might act injuriously by the increased pressure on the
chest, and also by the position not being a favourable one
for respiration. Dr. Markham has suggested that pos-
sibly the warm water bath might do harm by preventing
the access of air to the skin, and thus assist the state of
asphyxia.
I think we may, notwithstanding, conclude that the
warm bath may be considered as an auxiliary means,
and that much dependence is to be placed on both friction
and warmth, and that nothing should be allowed to
interfere with the application of those means by which
warmth is restored to the skin. “It ought certainly to
be borne in mind, that the practice of the Royal Humane
Society, whose rules, Dr. M. Hall states, ‘ may be
summed up in one word — warmth ! 9 has been eminently
successful.” (Vide British and Foreign Medical- Chirur -
gical Review , April 1858.) The impossibility of using
the warm water bath during the adoption of the postural
method of Dr. Marshall Hall is universally admitted.
In the apncea of still-born infants, momentary immer-
sion in baths of from 50° to 60°, and 98° to 100°, alter-
nately and quickly, might be tried, as recommended by
Dr. Hall.
It is well known that hot air increases respiration, a
person respires more frequently in hot air than in cold.
It also increases pulsation.
Cold also increases respiration, but acting only as shock
it does not increase pulsation.
Accordingly I would suggest the employment of a hot
air bath where practicable in case of suspended animation
as a general stimulant to both the respiration and circula-
tion, with the occasional application of cold to act on the
principle of shock, and so accelerate any respiratory efforts.
The air would have free access to the skin, and the
position of the body might be such as should be thought
desirable.
We now come to the third division of our subject.
The introduction of air into the chest.
1st. By the use of instruments.
The mechanical introduction of air into the chest by
means of the bellows, by Dr. Sibson’s or some other
apparatus, appears, theoretically speaking, to be strongly
8
indicated; but the obvious objection is, that the instru-
ments are not commonly at hand, and whatever is done on
these occasions must be done quickly. A similar remark
may be applied to the employment of electricity and
electro-magnetism, and the introduction of certain gases,
oxygen, ammonia, etc. Moreover, Mr. Mare states, that
“more good is done by drawing air out of the lungs than
by artificially inflating these organs.”
2nd. By taking advantage of certain movements of the
walls of the chest.
Under this division we come to the examination of
some of the various ways of introducing air by imitating
inspiration and expiration, employing with that view cer-
tain movements of the thoracic parietes . We will group
them under three heads : —
I. Alternate compression and relaxation of the walls
of the chest.
II. The postural method of Dr. Marshall Hall.
III. The method which I beg to introduce to your
notice.
I.
Alternate compression and relaxation of the chest .
This is the essential part of the various plans formerly
employed. On compression, the walls of the chest descend
below their accustomed level, the capacity of the lungs is
diminished, and air is expelled. Upon the removal of the
pressure or relaxation of the chest, the ribs rise again to
their usual and ordinary height, and air is again intro-
duced. There is no elevation of the ribs, such as takes
place in natural deep inspiration, in which they are made
to rise above their ordinary or quiescent level, and the
cavity of the chest greatly increased in size.
These methods have been made the subject of ex-
periment. The apparatus employed was very simple,
and consisted of three tubes, one of glass, to be passed
into the trachea ; another, a bent barometer tube,
graduated ; and these two connected by a piece of India
rubber tubing. The glass tube was passed through an
aperture made in the trachea, and firmly secured in its
place by a ligature. A small quantity of coloured spirit
was poured into the barometer tube, which was in the
form of an inverted syphon, and was retained in an
9
upright position, on a level surface, by an assistant who
carefully noted the height of the co-
lumn of fluid.
Trials were made on persons of both
sexes and of different ages, and at a
length of time after death which varied
from one hour and a half to two days,
in those with lungs sound or other-
wise. But practical deductions
HAVE BEEN DRAWN PROM THOSE
CASES ONLY IN WHICH THE RESULTS
WERE OBTAINED WHEN THE BODY
WAS WARM, AND WHEN TWO HOURS
HAD NOT ELAPSED AFTER DEATH.
This is very important, rigor mortis*
preventing trustworthy conclusions.
The chest should be free from
DISEASE.
The subject of experiment was
placed in various positions; and on
compression of the chest being made,
_ * i , , fluid contained in the inverted
of fluid. 2. Height to syphon, connected with the lungs by
pressure cm thickest the flexible tube> immediately rose;
3. Point to which the and, when the compression ceased,
flret iegCofethe'iLtrue the fluid fell slowly to its previous
ment by the drawing level, demonstrating
when the* ch est wasex- 1st. That air had been expelled from
panded by my method, the lungs — in consequence of the pres-
sure exerted on the parietes of the thorax.
2ndly. That the air returned into the chest, though
slowly, upon relaxation of the pressure — in consequence
of the feeble elasticity of the chest.
3rdly. That the actual capacity of the chest was not
increased by this mode of practice.
II.
Postural Method of Dr . Marshall Hall .
The principle involved in this method of treatment is
precisely the same as in the foregoing plan, in which
simple compression and relaxation of the chest are em-
* The commencement of rigidity usually takes place within
seven hours after death. Its general duration is from twenty-four
to thirty- six hours.
10
ployed to induce expiration and inspiration; the difference
being that, in the postural method, the compression of the
thorax is occasioned by the weight of the body of the
patient resting on the chest during the prone position,
followed by the removal of the pressure, and consequent
return of the thoracic parietes to their ordinary level on
the patient’s assuming the supine posture. No attempt is
made to enlarge the actual capacity of the chest by
inducing an elevation of the ribs, such as takes place on
making a deep inspiration. The following directions are
given for performing the postural method : — “ Place the
patient on his face, supporting the chest on a folded coat,
or other article of dress. Turn the body very gently but
completely on the side, and a little beyond, and then
briskly on the face, alternately repeating these measures
deliberately, efficiently, and perseveringly, fifteen times in
a minute only. ( When the patient reposes on the thorax ,
that cavity is compressed by the weight of the body , and
expiration takes place ; when he is turned on his sidef
this pressure is removed , and inspiration occurs .) When
the prone position is resumed, make equable but efficient
pressure with friction along the back, removing it imme-
diately before rotation on the side. ( The first measure
augments the expiration ; the second commences inspira-
tion.)”
Numerous experiments have been made on the dead
body in order to test the influence the postural method
has upon respiration. The following results were ob-
tained by the aid of the apparatus mentioned above,
namely, a glass barometer tube bent in the form of an
inverted syphon graduated, and containing a little
coloured spirit, made to communicate with the trachea by
means of a long flexible tube, the joints well secured by
ligature.
First: The subject of experiment being placed in the
prone position, equable but efficient pressure with friction
was made along the back, as recommended by Dr. Mar-
shall Hall, in his rules for restoring persons apparently
dead from apnoea. The fluid rose in the bent tube,
proving that the compression exercised on the thorax by
the weight of the body, etc., did displace some air from
the lungs.
Secondly : On turning the body on the side and a little
beyond, the column of fluid fell slowly to its former level,
11
proving that the air returned into the chest, though slowly,
upon the removal of the pressure — in consequence of the
return of the parietes of the chest, by their feeble elastic
force, to their natural level.
Thirdly : It was proved, by the fluid in the bent tube
not descending below its level, that the actual capacity of
the chest is not enlarged.
Fourthly : From the results of the experiments on
simple compression exactly corresponding with the results
of the experiments on the postural method, we may infer that
these two methods of treatment are identical in principle.
It must be remembered that it is only the “ residual
air,” or that which remains in the chest after an expira-
tion, which is operated upon in the postural method.
The Postural or Ready method of Dr. Marshall Hall
has been found open to some objections ; for instance : —
1. Expiration is made to precede inspiration, whereas
originally expiration is second in order, and not the
primary act. In still-born infants, whose lungs have
never been inflated, forced expiration, at first, is of course
impossible.
2. The expansion of the thorax, or inspiration, being
dependent on little more than the elasticity of the tissues,
takes place feebly, inefficiently, and slowly, and therefore
calls for more active mechanical aid.
3. It is scarcely possible to use the warm bath during
the adoption of the postural method.
4. The patient is liable to have the mouth and nose
compressed, the face bruised, or the neck twisted by the
almost lifeless body being turned alternately on the chest
and back fifteen times a minute for some hours. More-
over, to the operator this process is very arduous.
5. When the patient is turned on the face and pressure
made on the back (pronated) the contents of the stomach
are liable to pass into the oesophagus and windpipe.
6. When the patient is turned “ completely on the side
and a little beyond” (supinated), the tongue is apt to
obstruct inspiration by falling back into the throat, with
the epiglottis resting against the back of the pharynx.
7. Both sides of the chest are not equally inflated, one
side only being called into action at the same time to any
important extent.
8. This process is not entirely in harmony with that of
nature. It is not the way in which we generally breathe.
12
9. The amount of air respired is exceedingly small ;
this is, doubtless, in consequence of the actual capacity of
the chest not being increased.
As to the state of the tongue, I observe that, in cases
of asphyxia the tongue is usually swollen, and falls back
into the throat, acting as a plug to the pharynx, and
a sort of valvular covering to the otherwise patulous
orifice of the larynx. In the postural method, when the
body is turned on the face, no doubt the tongue falls
forwards and draws with it the epiglottis, and leaves the
glottis open. This, however, is of little consequence so
far as respiration is concerned, for the very compression of
the chest by the weight of the body itself forces out the
air from the lungs, and so lifts up the valvular covering of
the larynx, so that in fact the tongue does not offer any
serious obstacle to expiration when it is induced by com-
pression of the thorax.
Moreover, in the postural method, the moment the
patient is rolled “ on the side and a little beyond,” in
order that inspiration may take place, the tongue is liable
to fall back into the throat, and its semi-lifeless relaxed
tissue to cover securely the orifice of the glottis, and its
accurate closure is probably further insured by the suction
generated by the return of the thoracic parietes to their
natural level, so that the greater the previous compression
of the chest, the more firmly is the tongue drawn down
as a plug into the throat, when the pressure is relaxed,
and the more effectually does it prevent the entrance of
air into the lungs.
With reference to the amount of air respired in the
Marshall Hall method, Mr. Wildbore states in a letter to
the Medical Times and Gazette , Nov. 28th, 1858: u I
believe that I am correct in saying that the experiments
performed by Mr. Hunter and other gentlemen at St.
George’s Hospital on the dead subject, proved that nearly
as much air entered the lungs as would be inhaled in an
ordinary inspiration in a state of health;” that is, from
six to thirty cubit inches.
I think there must be some fallacy here. The method of
performing the experiments just mentioned is by no means
satisfactory, and is, I believe, open to obvious objections.
The tube of the pnseometer was passed into one of the
nostrils of the patient, the other nostril and lips being
closed with adhesive plaster. The want of rigidity of
13
cheeks and the amount of air in the respiratory tract
and even in the stomach, etc., of the patient could scarcely
fail to render the indications of the instrument, however
perfect in itself, liable to suspicion, if not entirely value-
less, in point of scientific accuracy.
In the Marshall Hall method, the amount of air dis-
placed from the chest and returning there is exceedingly
small,* being according to my experiments a fraction of
one cubic inch. Compression of the thorax does at first
expel some air, as may be seen above, but the repetition of
simple rotation has little effect in restoring it.
III.
Dr. Henry Silvester's , or the Physiological Method of
Inducing Respiration .
The new method which I venture to bring before the
profession is an imitation of natural deep respiration,
and is effected by means of the same muscles as are em-
ployed by nature in that process. In ordinary deep
inspiration we lift the ribs and sternum by the pectoral
and other muscles which pass between the chest and the
shoulders, and thus produce the threatened vacuum which
inflates the lungs. In my method we lift the ribs and
sternum by the pectoral and other muscles, which pass
from the shoulders to the parietes of the thorax, by
steadily extending the arms of the patient up by the side
of his head : by elevating the ribs the cavity of the chest is
enlarged, a tendency to a vacuum is produced, and a rush
of air immediately takes place into the lungs. Expiration
is brought about by simple compression of the sides of the
chest by the patients arms.
The Principle . Forced enlargement of the capacity of
the chest, producing a tendency to a vacuum, and conse-
quently an inspiration of air into the lungs, induced by the
constrained action of the muscles of ordinary and extraor-
dinary inspiration upon the moveable walls of the thorax.
Diminution of the capacity of the chest and expulsion of
the air from the lungs, and consequently an expiration in-
duced by compression of the moveable walls of the thorax.
The arms of the patient are to be used by the operator
as handles to open and close the chest.
* Vide the Beporfc of the Committee of the Medical Chirurgical
Society, page 4=3, below.
14
Fig. 4. Diagram of the Muscles iu Front of the Chest.
1. The pectoralis major arising from the clavicle and from the cartilages of the
true ribs, and converging towards the tendon of insertion into the bicipital
groove of the humerus.
2. The pectoralis minor, arising from the third, fourth, and fifth ribs, near their
cartilages, and converging to a tendon, which is inserted into the coracoid
process of the scapula.
8. The subclavis muscle, which arises froih the first rib, and is inserted into the
costal aspect of the clavicle for nearly half its length.
4. The serratus magnus, placed upon the upper and lateral parts of the thorax,
arising from the eight upper ribs, and inserted into the scapula.
5. The deltoid, which arises from the external third of the clavicle and from the
spine of the scapula, and is inserted into a prominence on the middle of the
outer side of the humerus.
All these muscles are put on the stretch, and tend to raise the ribs, when the arms
are extended upwards by the side of the head, as described in my method.
This new method has been tested by experiment on the
dead body by the same apparatus, the elastic tube being
securely fastened into the trachea, in order to avoid the
sources of fallacy mentioned above.
The body was placed on its back, supported and a little
raised by a small pillow placed under the shoulders. The
height of the column of fluid having been first carefully
noted, the arms of the subject were raised, and then
steadily extended upwards by the sides of the head, so
I
15
as to draw up the shoulders and put the pectorals on the
stretch, elevate the ribs, and consequently enlarge the
cavity of the chest. The result was that the fluid in the
bent tube rapidly fell, and so considerably as to recede
high up in the leg of the instru-
ment nearest to the body, that is to
say, the tendency to a vacuum pro-
duced in the chest drew the air into
the lungs.
The shoulders and arms were
next pressed down upon the sides
of the chest, and immediately the
fluid rose as much above its usual
level in the further leg of the ap-
paratus as it did in the foregoing ex-
periments ; demonstrating :
lstly. That the actual capacity of
the chest was increased, and air
drawn into the lungs by the con-
strained action of the muscles of
respiration upon the moveable walls
of the thorax.
2ndly. That expiration was pro-
duced by pressing the arms and
shoulders down upon the sides of
the chest.
3rdly. That the distinguishing fea-
ture of my method is the actual en-
largement of the cavity of the chest
— the elevation of the ribs above
represents the depression their ordinary or natural level.
of the chest under pres- 7. • n p
sure. Dotted line repre- ft 01 Course, of consequence
sents the enlargement of to get as much air into the lungs as
the chest, produced by the 0 1 .i ,
forced action of the mus- possible, because there can be but
des of inspiration. The little doubt that fresh air is the
space between the conti- .
nuous line and the broken proper stimulant to the respiratory
«8ptatoryemOTlment3%?i efforts, just in the same way that
the postural method. The light is to the eye and sound to the
space between the dotted 0 mv 1*. o • j
line and the broken line ear. The quantity of air respired,
indicates the extent of re- according to my experiments on the
my method. dead body, appears to be about ten
times greater in the method advocated than in the pos-
tural method of Dr. M. Hall, and would be amply suffi-
Fig. 2. — Continuous line re-
presents the ordinary state
of the chest. Broken line
16
cient to supply fresh air to the lungs of an asphyxiated
person.*
Fig. 3. Front view of the Bones of the Thorax.
Before laying down practical rules for the treatment of
apnoea, we may consider shortly the mechanism of re-
spiration in man.
The Mechanism of Respiration in Man.
The general principle of the operation is this : — The
lungs are divided into cavities of extreme minuteness ; and
these cavities or air-cells are all connected with the trachea
by means of the bronchial tubes. The lungs themselves
are suspended in a cavity that is completely closed, being
bounded above and around by the bony framework of the
thorax, the interspaces of which are filled up by muscles and
* With regard to the amount of air respired by my method. In
a body which had been dead three days, and rigor mortis was at
first strongly marked ; the Committee of the Royal Medical and
Chirurgical Society, appointed to investigate the subject of suspended
animation, found when performing my method, that a volume of air
was inspired amounting to 44 cubic inches, and on sternal pressure
52 cubic inches were expired. In ordinary tranquil breathing adults
usually inspire and expire on an average about 20 cubic inches.
17
membranes, and being entirely cut off from the abdomen
below by the diaphragm. Under ordinary circumstances,
the lungs completely fill the cavity. But the capacity of
the thoracic cavity is susceptible of being greatly altered
by the movements of the ribs, and by the action of the
diaphragm and abdominal muscles. When it is diminished,
the lungs are compressed, and a portion of the air con-
tained in them is expelled through the trachea. On the
other hand, when it is increased, the elasticity of the air
within the lungs causes them immediately to dilate so as
to fill the vacuum that would otherwise exist in the
thoracic cavity, and a rush of air takes place down the
air-tubes and into the remotest air cells, to equalise the
density of the air they include (which has been rarified
by the dilatation of the containing cavities) with that of
the surrounding atmosphere. The lungs themselves
appear to be almost entirely passive instruments of the
respiratory function. The dilatation of the cavity of the
chest, which constitutes inspiration, is accomplished by
two sets of movements — the elevation of the ribs, and
the depression of the diaphragm. In tranquil breathing
the contraction of the diaphragm is alone nearly sufficient
to produce the necessary enlargement of the thoracic
cavity, the position of the ribs being very little altered.
In the act of deep inspiration, the ribs (whose ordinary
direction is forwards, sloping downwards), under the
influence of their elevator muscles, namely, the pectoralis
muscles, major and minor, the serratus magnus, the
scaleni muscles, and the intercostals, pass from the sloping
to the horizontal position. By this change, the dimensions
of the chest are enlarged in the transverse as well as in
the antero -posterior direction, for the middle curved por-
tions of the ribs are carried outwards, and therefore
brought further apart from each other, and their sternal
extremities are moved forwards, accompanied by the
sternum, the distance of which from the dorsal vertebrae
is thereby increased. When the respiratory movement
is very forcibly performed, the scapula is itself drawn
upwards, thus producing an increased elevation of the
ribs and an unusual enlargement of the upper part of the
thoracic cavity. When deep expiratory action is to be
performed, the ribs descend by the action of the muscles
of the spine and the abdomen, the diaphragm being
B
18
altogether passive. In this manner, by the regularly
alternating dilatation and contraction of the thoracic
cavity, the air within the lungs is alternately increased
and diminished in amount, and thus a regular exchange
is secured. The number of the respiratory movements
(that is, of the acts of inspiration and expiration taken
together) may be estimated at from fourteen to eighteen
per minute. (Carpenter’s Physiology.)
I may also remark that, from the peculiar mode in
which the ribs are articulated with the spinal column at
one extremity, and from the angle which they make with
the cartilages that connect them to the sternum at the
other, the act of elevation tends to bring the ribs and
their cartilages more into a straight line, and to carry the
former to a greater distance from the median plane of the
body, whilst the sternum is also thrown forwards. Con-
sequently the elevation of the ribs increases the capacity
of the thorax, upwards, forwards, and laterally. Although
the range of motion between each vertebra and the ribs
attached to it is very limited, yet the whole framework of
the chest enjoys such mobility, that by a deep inspiration
its cavity is sometimes more than doubled.
I may also mention, that in difficult respiration the
muscles of the limbs are made to assist in respiration —
the patient seizing hold of any fixed object for the sake
of a firm point for the muscles to act from ; and that in
deep respiration the greatest enlargement of the thoracic
cavity in both sexes is made by the ribs, and not by the
diaphragm. It appears very questionable whether the
diaphragm is affected any further than being flattened,
and that without descending.
It is unnecessary to enter upon the chemical phenomena
of respiration.
I will now proceed to lay down a few practical rules
for inducing respiration in cases of asphyxia.
With regard to the Apncea of Still-Born Children , re-
spiration may generally be excited by dashing cold water
on the face and body, by blowing in the face, or by a slap
with the flat of the hand on the nates.
Should these measures fail, the following rules for in-
ducing respiration should be put in practice.
In cases of Narcotic Poisoning , artificial respiration
may by these rules be kept up for any length of time, or
until the poisonous matter is eliminated.
Fig. 5.— Diagram to illustrate the manner of performing my method. The as-
phyxiated patient is supposed to be in the act of drawing an inspiration. The
ribs being elevated by the operator, who is stretching upwards the patient’s aims.
The following Rules for the treatment of apnoea are
deduced from actual experiment, and are in accordance
with established physiological principles.
20
DR. HENRY SILVESTER’S RULES FOR RESTOR-
ING SUSPENDED ANIMATION.
Rule I.
To adjust the Patient's Position.
Place the patient on his back, with the shoulders raised
and supported on a folded article of dress, and secure the
feet.
, Rule II.
To Maintain a Free Entrance of Air into the Windpipe.
Wipe the mouth and nostrils. Draw forward the pa-
tient’s tongue, and keep it projecting beyond the lips. (If
the lower jaw he gently raised , the teeth may he made to
hold the tongue in the required position. Should it he
found necessary , the tongue may he retained in that posi-
tion by passing a handkerchief under the chin and fastening
it over the head.)
Rule III.
To Imitate the Movements of deep Respiration.
Raise the patient’s arms upwards by the sides of his
head, and then keep them stretched steadily but gently
upwards and forwards for two seconds. (This action
enlarges the capacity of the chest by drawing up the
ribs, and induces an inspiration .)
Next, turn down the patient’s arms and press them
gently and firmly for two seconds against the sides of
the chest. (This action diminishes the cavity of the
thorax, by pressing down the ribs, and produces a forcible
expiration .)
Repeat these measures alternately, deliberately, and
perseveringly fifteen times in a minute.
Rule IV.
To Induce Circulation and Warmth , and to Excite
Inspiration. ,
Rub the limbs from the extremities towards the heart.
21
Replace wet clothing by warm and dry covering. Occa-
sionally dash cold water in the* patient’s face. These
measures are perfectly compatible with the systematic
performance of the imitation of the movements of respir-
ation. A similar remark applies to the use of the warm
water bath, or hot air bath, if required.
Explanatory Remarks.
Rule t. The posture recommended is not essential ;
but in this position the vital capacity of the chest is
larger than in any other recumbent attitude. The bony
framework of the chest is more free to move, and both
sides can be expanded at the same time. This, in fact,
is precisely the posture chosen by persons suffering from
dyspnoea.
Rule ii. In this way the patulous orifice of the wind-
pipe is raised and drawn forward, so that nothing inter-
venes between it and the natural channel of air through
the nose. The tongue is entirely prevented from falling
back into the throat, whilst the extent to which the wind-
pipe is put on the stretch is clearly indicated. The
pharynx also is sufficiently opened to allow of the removal
of liquids, etc., from the mouth, nose, pharynx, etc., if
those have not been completely displaced by previous
suitable treatment.
Rule hi. This process in short accomplishes artifi-
cially for the patient exactly what he would himself effect,
and by the same muscles, if he had but the will and the
power to draw a deep inspiration.
When the ribs are raised the capacity of the chest is
enlarged, and a tendency to a vacuum is induced.
The ribs are raised by the pectoral muscles, and the
pectoral muscles are put on the stretch by the arms of
the patient, and the arms of the patient are drawn up
by the operator ; the result is that the ribs are raised and
the fresh air passes into the chest to occupy the enlarge-
ment thus produced ; and alternately with this the vitiated
air is expelled from the lungs by compression of the sides
of the chest.
Should there be any spontaneous efforts to respire —
and these efforts at first may not be repeated perhaps
more often than twice in a minute — they should on no
account be checked by officious interference. Great care
22
must be taken not to disturb the natural rhythm. The
expirations might be irfade a little more forcible or the
inspirations deeper, but that is all.
Possibly the elevated position of the arms, together
with the muscular compression exerted on the veins of
the upper extremities, might favour the descent of blood
from them into the chest at the same time that the
tendency to a vacuum produced in the thorax by the
elevation of the ribs would induce a rush of fresh air into
the lungs.
At the same time that the arms are extended steadily
upwards, the lungs might be filled with air by a mouth to
mouth inflation.
The following are some of the advantages of my
Method : —
1. Inspiration may be made to precede expiration, or it
may be second in order at the will of the operator.
2. The expansion of the thorax is artificially insured,
and is wholly under the control of the operator.
3. This method may be carried out when the patient is
in the warm bath.
4. The patient is not liable to be injured by the mani-
pulation.
5. The contents of the stomach are not liable to pass
into the windpipe.
6. The tongue is prevented from obstructing inspir-
ation.
7. Both sides of the chest may be equally inflated.
8. This process is entirely in harmony with that of
nature.
9. A larger amount of air is inspired than by any other
method.
10. This method is most easy of adoption.
11. Pure atmospheric air is inspired.
12. No apparatus is required.
Several successful cases of resuscitation have been re-
corded in the medical journals.
The following Directions I drew up as a foundation
for the Regulations of the Royal Humane Society at the
request of Dr. Christian, they are calculated to be gene-
rally useful.
23
DIRECTIONS FOR RESTORING THE
APPARENTLY DEAD
From Drowning, Suffocation, Hanging Strangling, Garot-
ting, Epilepsy, Chloroform inhalation, Noxious vapours,
Opium, or Narcotic poisoning.
Send immediately for medical assistance, blankets, and
dry clothing, but proceed to treat the patient instantly on
the spot, in the open air .
The points to be aimed at are — -first, and immediately ,
the Restoration of Breathing ; and secondly, after
breathing is restored , the Promotion of Warmth and
Circulation.
The efforts to restore life must be persevered in for three
or four hours .
Treatment to Restore Natural Breathing.
Rule I.
To Maintain a Free Entrance of Air into the Windpipe .
Cleanse the mouth and nostrils ; open the mouth ; draw
forward the patient’s tongue, and keep it projecting be-
yond the lips. Remove all tight clothing from about the
neck and chest. In the case of Drowning, in order to
insure the escape of fluids from the mouth and chest, in
the first instance place the body with the face downwards,
and hanging a little over the edge of a table, shutter, or
board, raised to an angle of about 30°, so that the head
may be lower than the feet. Open the mouth and draw
the tongue forward ; keep the body in this position for a
few seconds or a little longer if the fluid continues to
escape. The escape of fluid may be assisted by pressing
once or twice upon the back.
Rule II.
To Adjust the Patient's Position .
Place the patient on his back on a flat surface, inclined
a little from the feet upwards ; raise the shoulders, and
support them on a firm cushion or folded article of dress
placed under the shoulder blades. Keep the head in a
line with the body. In the apparently drowned the head
may be a little lower than the feet, to facilitate the escape
of fluids from the chest.
24
Rule III.
To Imitate the Movements of Breathing.
Draw upwards the patient’s arms until they nearly
meet above his head, the operator grasping them just
above the elbows, and keep them stretched steadily, but
gently, in an upward and forward direction, for two
seconds ( see Engraving I, Inspiration). ( This action
enlarges the capacity of the chest , by drawing up the ribs ,
and induces inspiration.)
Immediately turn down the patient’s arms and press
them gently and firmly for two seconds against the
sides of the chest ( see Engraving II, Expiration);
or upon the arms being lowered and replaced by the
side, moderate pressure may be made by both hands
of the operator upon the lower part of the front of
the chest. ( This action diminishes the capacity of the
chest , by pressing down the ribs , and produces a forci-
ble expiration .)
Repeat these measures alternately, deliberately, and
perseveringly, fifteen times in a minute, until a spon-
taneous effort to respire is perceived, immediately
* The Royal Humane Society has kindly allowed me the use of
these wood cuts, illustrating the position of the body during the
25
II. — Expiration.*'
upon which cease “ to imitate the movements of
breathing” and proceed to Induce Circulation
and Warmth ( as below).
In the apparently dead from chloroform or noxious
vapours, expiration should be made to precede in -
\ spiration.
Should a warm bath be procurable, the body may be
placed in it up to the neck, continuing “ to imitate
the movements of breathing.” Raise the body in
twenty seconds from the bath, and dash cold water
against the chest and face, and occasionally pass
ammonia under the nose.
Rule IV.
To Excite Inspiration .
During the employment of the above method excite the
nostrils with snuff, smelling salts, or tickle the throat with
a feather. Rub the chest and face warm, and dash cold
and hot (temperature 120° Fahr.) water alternately on
them.
employment of my method. They are from photographs taken
under my own superintendence.
26
Treatment After Na|ural Breathing has been
Restored.
Rule V.
To Induce Circulation and Warmth .
Commence rubbing the limbs upwards, over the dry
clothing, with firm grasping pressure and energy, using
handkerchiefs, flannels, etc. [By this measure the blood is
'propelled along the veins towards the heart.')
Promote the warmth of the body by the application of
hot flannels, bottles, or bladders of hot water, heated
bricks, etc., to the pit of the stomach, the armpits,
between the thighs, and to the soles of the feet.
Warm clothing may generally be obtained from by-
standers.
On the restoration of life, a teaspoonful of warm water
should be given, and then, if the power of swallowing
have returned, small quantities of wine, warm brandy
and water, or coffee, should be administered. The
patient should be kept in bed, and a disposition to
sleep encouraged.
I subjoin a report from the Lancet , of Dr. Christian’s
paper on “ Restoration from suspended Animation, ” read
before the Royal Medical and Chirurgical Society, with
some comments by Dr. Sharpey, F.R.S.
ROYAL MEDICAL AND CHIRURGICAL SOCIETY,
Tuesday, January 22nd, 1861. Mr. Skey, F.R.S., President, in
the Chair. On the Restoration of Suspended Animation in
Persons apparently Drowned. By Dr. Christian.
As to the mode of performing artificial respiration, the
method recommended by the Life-boat Institution is what Dr.
Marshall Hall called his “ Ready Method/' while that now used
by the Royal Humane Society is the method of Dr. Silvester.
On Dr. Marshall Hall bringing his method under the notice of
the Royal Humane Society, the Committee adopted means im-
mediately to give it a fair trial. Copies of his instructions were
sent to all their medical officers, numbering 120, and the boats
of the society on the Serpentine had a platform made on each,
on which to manipulate directly the body was taken from
the water, and the boatmen were instructed and practised in
the performance of the operation as he directs. After giving the
method a full trial in about fifteen cases, the very intelligent
superintendent, the boatmen, and the author became so satisfied of
its inefficiency to restore animation, and of the difficulty of pro-
perly carrying out the manipulations , that he felt himself justified
\i
27
in representing those facts to the Committee , and in adopting the
plan recommended by Dr. Silvester , which he believed in every way
to be superior , more manageable , less likely to injure the patient ,
will Jill the chest with and expel air from it more fully , and will
not force the contents of the stomach upwards , and in the way of
respiration.
The following are the directions for treating the asphyxiated
at the receiving house, Hyde Park : —
Wipe the mouth and nostrils directly the body is taken from
the water.
Use Dr. Silvester’s method; at the same time let the body be
taken as quickly as possible to the receiving-house, and place it
in the bath up to the neck.
Eaise the body in twenty seconds from the water, and dash
cold water against the chest.
Pass ammonia, under the nose. Use again Dr. Silvester’s
method , and the inflating apparatus if it fail.
Eemove the body from the bath and rub the surface with
dry hot towels, perseveringly continuing the other treatment.
After many experiments, the author had come to the con-
clusion that inflation of the lungs by Dr. Silvester’s method, or
by the Society’s apparatus, is the first remedy, and the shock of
the warm bath the second ; that after eight minutes’ complete
submersion, recovery is hopeless ; and that when ten minutes
elapse, after being taken from the water, without any effort at
respiration, it is equally so.
On the subject of the warm bath, which has excited so much
discussion as a remedy, he remarked that it must be understood
that it is used as an immediate and powerful excitant ; and it
had so frequently happened, (twice while he was actually pre-
sent) that a person brought in as asphyxiated, who, to the by-
standers, was apparently quite dead, immediately on being
placed in the bath, gave the sob or gasp, which is the precursor
of respiration, that it might be boldly stated to be a most
valuable adjunct to treatment, and properly managed in no
way pernicious.
Dr. Sharpey having had the honour of presenting the paper
to the Society, could not let it pass without remark
He would observe, with reference to the method of Dr. Marshall
Hall, that he had on one occasion spoken favourably of it, but
had seen reason to alter his opinion after more mature consider-
ation of the subject, and after hearing the practical experience
of the Eoya! Humane Society. Dr. Sharpey considered that
Dr. Marshall Hall’s method could only claim one advantage,
and it was not clear that it had even that. This supposed
advantage is that the tongue falls forward, and thus does not
embarrass respiration. He thought that Dr. Silvester’s method
attained this object without any of the disadvantages of the Ready
Method.
The disadvantages of the Eeady Method were several.
It must be remembered that a body submerged for some
time is practically a dead body, and serious mischief has not
unfrequently arisen from rough handling. Again, the constant
28
turning of the body renders it very difficult to apply warmth, or
carry out the other auxiliary means systematically ; but, above
all, it does not even fulfil its first object of changing the air in
the chest.
Dr. Marshall Hall cited experiments in support of his view ; but
the want of precision in making them is very striking. He (Dr.
Sharpey) could not attach any importance to the results of ex-
periments so conducted. Dr. Silvester had repeated them in a
more precise way, and could not get a displacement of more than
one cubic inch of air.
It would be asked, however, what answer should be made to
the many statements of the success of the Ready Method. He
would reply, that many of them were in cases of still-born infants,
a part of whom, he believed, would recover without any assist-
ance if left alone to themselves, or, at least, by very simple
means. Then again, as Dr. Silvester states, there is no air in
the lungs of infants. In reference to adults, he (Dr. Sharpey)
believed himself right in saying that in many of the cases of re-
covery after submersion, respiration commenced spontaneously
as soon as the patient reached the air. If in such cases Dr.
Marshall Hall’s method is began at once, it would be unfair to
give the credit solely to it. May it not even be, as suggested by
Sir B. Brodie, that recovery often follows, not from the means
used, but in spite of them P
SIR B. BRODIE, BART., F.R.S.,
On the Marshall Hall and Silvester Methods.
The restoration of persons apparently drowned has been at-
tracting so much attention since Dr. Christian’s able paper was
read before the Medico-Chirurgical Society, that the two follow-
ing letters from Sir Benjamin Brodie will be read with in-
t©r©st *
14, Saville Row, February 13, 1860.
Dear Sir, — I cannot say that I have ever entertained any favour-
able opinion of what the late Dr. Marshall Hall called his “ Ready
Method of restoring animation.” It seems more than probable
that the repeated compression of the chest, for the purpose of
expelling all the air from the lungs, would have an injurious
effect on the action of the heart. The air drawn into the lungs
by the elasticity of the parietes, or walls of the chest, would fall
very short of that inhaled in an ordinary inspiration, and this
opinion is confirmed by the experiment of Dr. Silvester.
Then the mechanical disturbance, occasioned by the continual
rolling and tumbling about of the body, cannot, I apprehend, be
otherwise than mischevious where the chances of life and death
% are equally balanced, and must, in all cases, interfere with the
natural process of recovery.
By the method proposed by Dr. Silvester , certainly more air
would be drawn into the lungs than by that of Dr. Marshall Hall ,
and with much less disturbance to the body generally. In some
animals, as the rabbit, a very sufficient quantity of air can be
drawn into the lungs by a similar method, that is, by the mere
29
elevation of the ribs. How far in the human subject Dr. Sil-
vester’s process would be a sufficient substitute for natural
respiration, I do not venture to say ; it is a question to be de-
cided only by experiment.
Where the apparatus of the Eoyal Humane Society for the arti-
ficial inflation of the lungs is at hand, I have no doubt that
this affords the surest and safest means for imitating natural
respiration if the necessary precautions are observed in using it.
At the same time, I have no doubt that the late intelligent me-
dical assistant of the Eoyal Humane Society at Brompton, Dr.
Woolley, was correct when he informed me that practically the
cases of drowned persons, in which artificial respiration can be
employed with advantage, are very few indeed. The first thing
to be done is to take the body out of the water as soon as pos-
sible, it being always borne in mind that the case is one which
admits of no delay, as except under some very rare and peculiar
circumstances, there is little chance of life being restored where
the period of complete submersion exceeds three minutes and a
half. The next thing is to do nothing that can interfere with
the natural process of recovery. It is only in those cases in
which there is no sign of any effort to breath spontaneously that
artificial respiration should be had recourse to, and it is only in
a small proportion of these that it proves successful. If you or
any one else should be desirous of knowing what more I have to
say on the subject of the treatment of those who suffer from
strangulation or drowning, I would refer you to what I have
published in my volume of “ Lectures illustrative of certain
points in Pathology and Surgery.”
I am, dear Sir, yours very truly,
B. C. Brodie.
Lambton J. H. Young, Esq.,
Secretary to the Eoyal Humane Society.
Victoria Hotel, St. Leonard’s-on-Sea, October 11, 1860.
Dear Sir, — I observe that the first instruction of the Eoyal Hu-
mane Society with regard to the treatment of drowned persons is
“ that no time should be lost.” I conclude, therefore, that these
instructions agree with those of the Life Boat Institution ; that
there should be no delay in carrying out whatever measures are
necessary for the purpose of resuscitation. I also conclude, that
it never could have been intended that the drowned person
should be taken to a house if the house were not close at hand.
The only real difference of opinion then seems to be as to the
use of the warm bath and the method to be adopted, with a view
to restore respiration. Now, with regard to the first of these
points, what is really wanted is that the body should not lose
its natural heat, and whether this be accomplished by dry ap-
plication, or by moist application, as the moisture cannot pene-
trate beyond the cuticle, would appear to be of small importance ;
and I own that the practical observations on the use of the warm
bath, made by the officers of the Eoyal Humane Society, seem
to me to be more likely to lead us to the truth, than the theore-
30
tical objections to it made by Dr. Marshall Hall. At the same
time, I certainly think it important that the temperature of the
bath should be rather below — certainly not above the natural
temperature of the living body.
With regard to the second point, I do not know that I need
do more than refer to what I have said on the subject of Dr.
Marshall Hall’s proposal. In a letter which I wrote you on the
subject formerly, and which is printed in one of the Royal Hu-
mane Society’s reports,* I may, however, take the oportunity of
briefly stating : —
1st. That the interval, during which artificial respiration can
be employed is very limited.
2ndly. That if the Royal Humane Society’s apparatus be at
hand, and the medical man present knows how to use it, this
affords by far the safest and surest method of imitating natural
respiration.
3rdly. That there is great danger, that the rolling and tum-
bling about of the body, as proposed by Dr. Marshall Hall,
would interfere with the natural process of recovery ; at the
same time, that it is very doubtful, whether by this method a
sufficient quantity of air could be drawn into the lungs to answer
any useful purpose.
4thly. That , at any rate , of the two methods that of Dr. Silvester
would be much more effectual , and much less calculated to do
injury.
In the treatment of drowned persons, as in the treatment of
disease, the first rule of the medical art is to do nothing that
may interfere with the natural process of recovery. When a
drowned person is first taken out of the water, if the heart have not
actually ceased acting, there is generally a spontaneous effort to
respire ; that effort may not be repeated perhaps more than twice
in a minute, or even not so often in the first instance. But if
the attempt to respire has once began, it will, in the majority of
instances, continue, the intervals becoming gradually shorter ;
and I cannot doubt that rough usage, as that which Dr. Marshall
Hall recommended, would interfere with it, although it is not
very improbable that every now and then some one may recover
in spite of it. With regard to the authorities referred to in
favour of the practice of rolling about the body, I may observe : —
1st. That I do not know who are the medical bodies referred
to as having approved of Dr. Marshall Hall’s method. I cer-
tainly never heard of the question having been submitted to any
of the medical colleges or universities.
2ndly. That I attach little importance to the names of three
hundred medical men, who are said to have signed a memorial
on the subject, knowing, as I do, how easy it is to procure a
great number of signatures to any document, when you have
two or three names to begin with ; and knowing also that the
question as to the mode of death from drowning, is altogether a
physiological one, to which the attention of very few medical men
# Letter printed above.
31
has been directed, with the exception of those who are actually
engaged in teaching physiology.
I send you these observations in compliance with your request ;
my conclusions have not been hastily formed. The mode of
death from drowning, and the treatment afterwards required,
formerly occupied a great deal of my attention, and was the sub-
ject of a great number of experiments on animals ; but I have
not trusted to these alone, having had frequent conversations on
the subject with a very experienced and intelligent officer of the
Royal Humane Society, the late Dr. Woolley, and since then with
Dr. Christian. Yours truly,
L. J. W. Young, Esq., Secretary. B. C. Brodie.
ROYAL MEDICAL AND CHIRUROICAL SOCIETY,
Tuesday , July 1st , 1862. Dr. Babington, President , in the
Chair. Report of the Committee appointed to investigate the
subject of Suspended Animation .*
The inquiry was conducted —
By means of experiments upon living animals ;
By means of experiments upon the dead human body.
In investigating anew the subject of apnoea by means of ex-
periments on the lower animals, it seemed expedient to observe,
in the first place, the principal phenomena of apnoea in its least
complicated form — namely, when produced by simply depriving
the animal of air.
The principal facts to which attention was directed during the
; progress of the apnoea thus induced were —
The duration of the respiratory movements ;
The duration of the heart’s action.
The duration of the heart’s action was observed —
(a) In relation to the duration of the respiratory movements.
(b) In relation to the time after the stoppage of the breath-
ing.
From the experiments performed it appeared that in the dog
the average duration of the respiratory movements after the
animal has been deprived of air is 4 min. 5 sec., the extremes
being 3 min. 30 sec. and 4 min. 40 sec. The average duration
of the heart’s action is 7 min. 11 sec., the extremes being 6 min.
40 sec. and 7 min. 45 sec.
From these experiments it appears that on an average the
heart’s action continues for 3 min. 15 sec. after the animal has
ceased to make respiratory efforts, the extremes being 2 min.
and 4 min. respectively.
Rabbits on an average ceased to make respiratory efforts in
3 min. 25 sec. Their hearts’ action stopped in 7 min. 10 sec. ;
consequently the interval between the last respiratory effort
and the cessation of the heart’s action was 3 min. 45 sec.
The next question investigated was — the period after the
# A portion of this Report is extracted from the “Lancet,” the
rest from the “ Transactions of the Royal Medical and Chirur-
gical Society.”
32
simple deprivation of air at which recovery is possible, under
natural circumstances, without the aid of any artificial means
of resuscitation.
The experiments performed led to the conclusion that a dog
may be deprived of air during 3 min. 50 sec., and afterwards
recover without the application of artificial means ; that a dog
is not likely to recover, if left to itself, after having been de-
prived of air during 4 min. 10 sec.
The force of the inspiratory efforts during apncea was ob-
served in the experiments to be so great that it was determined
to measure them. They were found to be capable, in the dog,
of raising a column of mercury four inches. It appeared, more-
over, that their force increases up to a certain period.
In other experiments, plaster of Paris, and even mercury,
were thus drawn upwards into the minute bronchial tubes.
It is easy to understand, therefore, how foreign bodies may
be drawn into the lungs in cases of drowning, and the import-
ance of this fact in the consideration of the pathology and
treatment of apnoea.
The Committee next passed on to the subject of drowning.
The first question investigated was — For what period can an
animal be submerged, and yet recover without the aid of arti-
ficial means ?
It was found as the result of numerous experiments on dogs
that, in striking contrast to the previous ones, 1^ minute* s im-
mersion in water suffices to destroy life.
Other experiments satisfactorily showed that the difference
of time between simple apnoea and that by drowning is not due
to submersion, or to depression of temperature, or to struggling,
but that it is connected with the fact, that in the one case a free
passage of air out of the lungs, and of water into them, is per-
mitted ; in the other, the exit of air and the entrance of water
are prevented.
There can be no doubt, from other considerations put forward,
that although both these circumstances are concerned in pro-
ducing the difference observed, yet that it is mainly due to the
entrance of water and the effects thereby produced.
The treatment of apnoea was next considered.
For conclusions respecting artificial respiration, the Com-
mittee refer to the second portion of the report.
Many other methods of resuscitation which have been recom-
mended were employed, including actual cautery, venesection,
cold splash, alternate application of hot and cold water, gal-
vanism, puncture of the diaphragm.
Although some of the above means were occasionally of
manifest advantage, no one was of such unequivocal efficacy in
a sufficient number of cases as to warrant the Committee in
specially recommending its adoption.
The experiments upon the dead subject were made with a
view to determine the value of the various methods which have
been employed for alternately compressing and expanding the
cavity of the chest in such a manner as to imitate the natural
fnovements of the thoracic walls in breathing. The following
methods have been investigated : —
33
1. Pressure exerted by the hands on the anterior wall of the
thorax, the body being in the prone posture. Such pressure
has for its object, to expel a portion of the air contained in the
chest : on relaxing the pressure, the chest expands and air
enters.
2. The postural or so-called " ready ” method, described by
Dr. Marshall Hall, which consists essentially in turning the
body gently on the side and a little beyond, and then briskly
on the face alternately and in making pressure along the
back of the chest each time the body is brought into the prone
position.
3. The method of Dr. Silvester, in which the action of the
pectoral and other muscles passing from the shoulders to the
parietes of the chest in deep inspiration is imitated. An in-
spiratory effort is produced by extending the arms upwards by
the sides of the head ; on restoring them to their original posi-
tion by the side of the body, the expanded walls are allowed
to resume their previous state, and expiration takes place,* the
quantity of air expelled being in proportion to that which had
been previously inspired.
It being necessary to measure the flow of air in and out of
the respiratory cavity under conditions of pressure closely re-
sembling those which exist in natural respiration, no means of
measurement could be used, which, in its working, would offer
any appreciable resistance to the passage of air. With this
consideration in view, an instrument designed by Dr. Sanderson
was employed.
A cylinder of glass, three inches in diameter, is suspended by
its closed upper end in a suitable cylindrical receiver of larger
dimensions, half filled with water, in the same manner as the
cylinder of an ordinary spirometer. Instead, however, of being
supported as in the spirometer by an arrangement of pulleys,
the cylinder is connected by a chain with one end of a scale-
beam which bears at its opposite end a counterpoise. The
weight of the counterpoise is equal to the weight of the cylinder
when its open mouth is plunged to a given depth in the water
of the receiver, care being taken that .the air included in the
cylinder shall communicate freely with the atmosphere. The
scale-beam is supported at its centre of gravity by a knife edge,
resting on a steel surface, so as to secure perfect freedom of
movement. With the same view, the end of the beam on which
the cylinder rests is furnished with a knife edge, on which the
bearing of the latter is supported ; the other end is prolonged
into a needle or pointer, the movements of which are indicated
on a graduated brass scale or circle, and the whole is so adjusted
as regards the quantity of water in the receiver, that the beam
shall be horizontal, in which position its index points to 0 of the
graduation. Air enters or escapes from the measuring cylinder
by a (J -shaped tube, one leg of which is in the axis of the re-
* Vide page 13. — Expiration is brought about by compression
of the sides of the chest by the patient's arms.
c
34
ceiver, its open end rising above the level of the water; the
other outside of the receiver is furnished with a stop-cock, and
connected with the respiratory cavity when the apparatus is in
action. To effect this connection, a T -shaped tube of gutta-
percha is employed. The cross-bar, about seven-tenths of an
inch in width, is adapted to the trachea by one of its ends ; the
stem of the T is connected with the stop-cock by a length of
flexible tube.*
In such an instrument it is obvious that the quantity of air
contained in the cylinder is indicated by the position of the
beam, and consequently of the pointer. The graduation of the
scale was effected by introducing measured quantities of air
through the stop-cock, and marking off the successive positions
of the needle, the apparatus having been first so adjusted as to
stand at zero at the commencement of the operation. The
numbers on the scale express in cubic inches the quantity of air
m excess of the quantity at first contained. The measurement
is subject to an error, arising from the fact that the weight of
the cylinder varies inversely as the proportion of it which is im-
mersed in water, but the amount of this error is so inconsider-
able that it may be entirely disregarded. The receiver was
furnished with a water manometer, or pressure gauge, by which
the effects of these differences of weight were at all times shown;
in no position of the apparatus did the depression of the column
exceed four-tenths of an inch, so that the error could in no in-
stance amount to more than 1000th part of the whole volume of
air contained in the apparatus and in the thorax together.
In all the experiments, the measuring apparatus was directly
connected 'with the trachea, the object in view being to deter-
mine the changes of capacity of the respiratory cavity under the
most simple conditions possible.
* The Royal Medical and Chirurgical Society has kindly allowed
me to make use of this illustration .
35
Experiments on the dead body, to determine the best method of in-
troducing air into the lungs .
February 24th, 1862. — At St. Bartholomew's Hospital.
Subject I. — A middle-aged, well-formed man, dead several
days; commencing decomposition; chest natural in form, and
normally resonant on percussion, except in the right lower
lateral region, where it was dull.
Observation 1. — Dr. Silvester's method. Body lying on back,
head hanging a little over the edge of the table. Gradual ex-
tension and elevation of both arms was attended by the
introduction of 17 cubic inches of air into the lungs. On re-
placing the arms to the side, 15 cubic inches of air were expelled
from the lungs.
Obs. 2. — Repetition of the above. On extension of arms 18
cubic inches were inspired, on restoration of arms to side 16^
cubic inches were expired.
Obs. 3. — Repetition of observations 1 and 2. On extension of
arxhs 16 cubic inches inspired. On depression of arms 14i cubic
inches expired. These observations were again repeated several
times, and with very similar results.
Obs. 4. — To show effect of pressure upon the sternum. Gra-
dual and moderate pressure with the hand upon the lower part
of the sternum expelled 15 cubic inches of air. Relaxation of
the pressure was followed by the introduction of 9 cubic inches
of air.
Obs. 5. — To show effect of Dr. Silvester’s method combined
with pressure on the sternum. On extension of the arms 17^
cubic inches of air were inspired. On depression of the arms 15
cubic inches of air were expired. On making pressure upon the
middle of the sternum, 8 additional cubic inches were expelled,
i. e., 23 cubic inches altogether.
Obs. 6. — Repetition of Silvester’s method and pressure. On
extension of arms 17 cubic inches were inspired. On depression
of arms 13 cubic inches were expired. On making pressure upon
the lower part of the sternum 11 additional cubic inches were
expelled, i. e., 24 cubic inches altogether.
Obs. 7. — To show effect of pressure on lower part of sternum
alone. This caused an expulsion of 10 cubic inches of air.
Obs. 8. — To show effect of pressure with the hands applied
simultaneously to both sides of the chest. This caused an ex-
pulsion of 8 cubic inches of air.
In each of the above experiments to show the influence of
pressure, a block was placed under the shoulders of the subject.
The degree of pressure exerted was moderate, and not more than
might be applied to the living body without injury.
Obs. 9. — Dr. Marshall Hall's method. At the commencement
of the observation, the body was lying on the back. On turning
it to the left side, 2£ cubic inches of air were inspired. On
placing it on the abdomen, 7 cubic inches of air were expired.
On restoring the body to the supine posture, very little inter-
change of air took place.
36
On repeating the other methods with this body, no uniform
or definite results were now obtained; it was thought that
some obstruction to the air-passages, from fluid or otherwise,
had been caused by the postural change in the Marshall Hall
method. No further observations, therefore, were made with
this subject.
* Subject II. — Same day and place. The body of an apparently
healthy young man, who had been killed by concussion of the
brain, caused by falling from a cab ; dead about three days ; no
signs of commencing decomposition. No evidence of fractured
ribs, or of any external injury. Grood resonance on percussion
over the front and sides of the thorax.
Obs. 10. — Marshall Hall method. Body lying supine at the
commencement of the observation. When turned on to the
side, there was no indication of an interchange of air, the index
remaining motionless. When the body was turned to the prone
posture, cubic inches of air were expelled. When the body
was restored to the supine posture, 2 cubic inches were found to
have been inspired during the movement from the face to the
back. The observation was repeated, the body being rendered
prone, and then restored to the supine posture, but no inter-
change of air at all was now indicated. The small amount of
air moved in the first of these two observations, and the nega-
tive result of the last, led to a careful inspection of the appara-
tus, to see if it was in fault ; but it was found to be in perfect
working order, as the results of the succeeding observations will
show.
Obs. 11. — To show effect of pressure on the lower part of the
sternum. Moderate pressure expelled 10 cubic inches of air.
Relaxation of the pressure was followed by the introduction of
the same amount of air, namely, 10 cubic inches.
Obs. 12. — Pressure on the middle of the sternum expelled
8 cubic inches of air, and a like amount of 8 cubic inches was
inspired on relaxing the pressure. The last two observations
were repeated several times, and were uniformly attended with
the same result, showing that 2 more cubic inches of air were
interchanged during lower than during middle sternal pressure
and relaxation.
Obs. 13. — To show effect of middle and lower sternal pressure
combined. The result was the same as when lower sternal pres-
sure alone was practised, namely, an expulsion of 10 cubic inches
of air, followed by the inspiration of a like amount of 10 cubic
inches on relaxing the pressure.
Obs. 14. — To show effect of lateral pressure with both hands.
Pressure on both sides simultaneously applied, expelled 11 cubic
inches of air; a corresponding amount of 11 cubic inches were
inspired on removing the pressure. This pressure was made
rather firmly.
Obs. 15. — Dr. Silvester’s method. On elevating the arms 18
cubic inches of air were inspired. On replacing the arms to the
side, 16 cubic inches were expired. On repeating this observa-
tion, 14 cubic inches were inspired ; 11 expired.
Obs. 16. — To show effect again of sternal pressure and relaxa-
37
tion. This process was repeated several times in succession, and
with the constant result of from 8 to 10 cubic inches of air being
interchanged each time. In this observation, ordinary respira-
tory murmur was distinctly heard on applying the stethoscope
to the chest during the interchange of the air.
Obs. 17. — Dr. Silvester’s method. This was again repeated,
and an average result obtained, that about 17 cubic inches of
air entered and left the lungs each time.
Obs. 18. — To show effect of pressure by means of a broad
bandage encircling the chest. This was practised several times,
and showed, as an average result, that from 8 to 10 cubic inches
of air were expelled by the pressure, and re-entered on relaxing
the pressure.
March 19th, 1862. — At St. Mary’s Hospital.
Subject III. — A middle-aged thin man, dead about three
days, no decided signs of decomposition ; rigor mortis strongly
marked; chest tolerably resonant on percussion, except over
lower half of right side, where it was dull.
Obs. 1. — Dr. Silvester’s method. On gradually raising the
arms, 24 cubic inches of air were inspired. On replacing the
arms to the side, 23 cubic inches were expelled.
Obs. 2. — Repetition of the above. On raising the arms 26’6
cubic inches were inspired. On replacing the arms 27*8 cubic
inches were expired.
Obs. 3. — Repetition of the above. On raising the arms 25-4
cubic inches were inspired. On replacing the arms 25*4 cubic
inches were expired.
Obs. 4. — On laying a 5^ lb. weight upon the lower part of the
sternum 0*35 of a cubic inch of air was expelled.
Obs. 5. — The last observation was repeated several times,
with the view of determining how much air could be expelled
by that amount of sternal pressure ; the average result was 025
of a cubic inch.
Obs. 6. — On making moderate pressure with the hands over
the lower part of the sternum 12*1 cubic inches were expelled.
On relaxing the pressure, 8*4 cubic inches were inspired.
Obs. 7. — On repeating the last observation 11 cubic inches
were expelled by the pressure, 9*7 cubic inches inspired on with-
drawing it.
Obs. 8. — Another repetition of the same. 11 cubic inches
were expelled by the pressure; 11 cubic inches were inspired
on relaxing it.
These observations, showing the influence of moderate hand
pressure upon the lower part of the sternum, were repeated
several times, and gave the same general result, namely, that
from 10 to 12 cubic inches of air were interchanged by the alter-
nate pressure and relaxation.
Obs. 9. — Dr. Silvester’s method repeated. On extension of the
arms 29 cubic inches of air were inspired. On replacement of
the arms to the sides, 26*6 cubic inches were expelled.
Obs. 10. — Repetition of last observation ; results the same.
Obs. 11. — Another repetition. Extension of arms caused 29
cubic inches to be inspired. Replacement of arms caused a cor-
responding amount of 29 cubic inches to be expired.
38
Obs. 12. — Results not reliable.
Obs. 13. — To show the effect of Dr. Silvester’s method when
combined with pressure on the sternum. On raising the arms,
29 cubic inches of air were inspired. On replacing them, 29
cubic inches were expired. On adding sternal pressure, 12
more cubic inches were expelled, giving a total of 41 cubic
inches interchanged.
Obs. 14. — To determine the quantity of air which could be in-
troduced into the lungs by elevation of the lower ribs, so as to
imitate the action of the diaphragm. On raising the lower ribs
on the two sides simultaneously, by means of the hands, and
then allowing them to subside, it was found that about 5 cubic
inches of air were thus interchanged.
Obs. 15. — Repetition of the last observation : results the same.
Obs. 16. — To determine the quantity of air interchanged by
alternate compression and relaxation of the sides of the chest.
On pressing both sides simultaneously, with the hands, and
then relaxing the pressure, it was found that about 5*3 cubic
inches of air were interchanged. On applying stronger pressure,
7*3 cubic inches were interchanged.
Obs. 17. — Dr. Silvester’s method was again tried, and with re-
sults similar to those last recorded.
Obs. 18. — A failure. Obs. 19. — A failure.
Obs. 20. — Dr. Marshall Hall’s method. When the body was
turned from the supine posture to one side, 7*2 cubic inches of
air were inspired. On turning the body on the face, 7*2 cubic
inches were expelled. On making pressure over the back, 8*5
additional cubic inches were expelled, giving a total of 15*7
cubic inches of air expelled by this method.
Obs. 21. — The last observation was repeated, but the amount
of air now interchanged was very much less, being scarcely 2
cubic inches during simple rotation. Pressure on the back,
however, when the body was prone, expelled between 7 and
8 cubic inches more.
Obs. 22. — Another repetition of the same method : results the
same as in Obs. 21.
Obs. 23. — Dr. Silvester’s method again tried. On raising the
arms, 44 cubic inches of air were inspired. On replacing the
arms, 38*6 cubic inches were expired.
Obs. 24. — Repetition of the last observation. Results about
the same, proving an interchange of nearly 40 cubic inches of
air by this method.
Obs. 25. — Another repetition of this method. Extension of
arms caused 38*6 cubic inches to be inspired. Replacement
of arms was attended by the expulsion of a like amount of 38*6
cubic inches.
During the last few experiments the rigor mortis had been
greatly overcome, and the upward movement of the arms could
be practised much more readily than at first, and much as it
would be during life or suspended animation.
March 20th, 1862. — At St. Mary’s Hospital.
Subject I-IIa. — The same body as in the last observation.
Obs. 1 and 2. — Dr. Silvester’s method. Extension of arms in-
troduced 41 cubic inches of air into the lungs. Replacement of
39
arms to side caused 41 cubic inches to be expelled. Pressure on
the sternum expelled 10 additional cubic inches of air, giving a
total expulsion of 51 cubic inches. On relaxing the sternal pres-
sure, 7 cubic inches were inspired.
Obs. 3 and 4. — Repetition of last. On elevation of arms, 42
cubic inches of air introduced. On replacement, 42 cubic inches
of air expired. On sternal pressure, 10 additional cubic inches
expelled, giving a total of 52 cubic inches expelled. On relaxing
the sternal pressure, 7 cubic inches were again inspired.
Obs. 5. — To show the influence of weight laid upon the
sternum. A 7 lb. weight on the sternum expelled 1 cubic inch
of air ; a like amount re-entered the chest on removing the
weight.
Obs. 6. — Weights to the amount of 14 lb. expelled 3 cubic
inches. A like amount of air re-entered on removing the weights.
Obs. 7. — Weights to the amount of 20 lb. expelled 4 cubic
inches. The amount which re-entered on removing the weights
was not noted. In the last three observations the weights were
placed upon a board lying in the axis of the body, so as to diffuse
the pressure.
Obs. 8. — Twenty pounds in weights lying across the lower part
of the sternum, expelled 6 cubic inches of air ; 5 cubic inches re-
entered the chest on removing the weights.
Obs. 9. — Repetition of Observation 8 : results the same.
Obs. 10. — Weights to the amount of 20 lb. laid across the up-
per part of the sternum expelled 5 cubic inches of air ; 4 cubic
inches re-entered on removing the weights. No increase in the
amount of air expelled took place on moving the weights lower
down the sternum.
Obs. 11. — Pressure with the hands on the lower part of the
sternum expelled 6 inches ; 4 cubic inches re-entered on with-
drawing the pressure.
Obs. 12. — On applying the stethoscope to the thorax, while
Silvester's method of imitating respiration was being employed,
a distinct and continued subcrepitant rale was heard during in-
spiration, and also, though less in duration and strength, in
expiration. The surface of the thorax was not cedematous, as
proved by division of the skin. The results were the same when
the stethoscope was applied over the denuded muscles of the
thorax as over the skin.
March 24th, 1862. — At St. Bartholomew's Hospital.
Subject IY. — A middle-aged, emaciated man, died of phthisis
and destitution; dead about three days. Rigor mortis moderate.
Apex of right lung rather dull on percussion.
Obs. 1. — To determine amount of air introduced into lungs
without opening the trachea. The nose and mouth were covered
with the mouth-piece of an inhaling apparatus and made quite
air-tight, except where communicating with the tube of the in-
strument employed for the purpose of the observation. The
body was placed supine ; the head hanging back over the edge
of the table. On applying the Silvester method of inspiration
no air was drawn into the chest.
Obs. 2. — Repetition of the above, with the exception that the
40
head was placed level on the table : the same negative result
was observed.
Obs. 3. — Another repetition : the head now turned to one side;
result the same.
Obs. 4. — Another repetition : body placed on abdomen, fore-
head resting on arm : the same negative result.
Obs. 5. — Position the same as in Observation 4; pressure now
made on the back expelled one cubic inch of air, which re-
entered the chest on relaxing the pressure.
These observations showed that there was some obstruction
interfering with the entrance of air into the chest. The mouth
was rather firmly clenched, and was with difficulty forced a little
open, yet the nostrils were probably free ; it was thought, there-
fore, that most likely the obstruction was situated about the
glottis, and occasioned by the tongue.
Obs. 6. — The trachea was now opened and a tube introduced
and secured, as in all the previous observations. Silvester
method. Only about cubic inches of air could be inter-
changed. Probably some obstruction in the lungs or air-pas-
sages.
Obs. 7. — Marshall Hall method. Only about 1^ cubic inches
of air could be interchanged by this, as by the last method.
Further experiments with the body were, accordingly, not
tried.
March 24th, 1862. — At St. Bartholomew's Hospital.
Subject Y. — A middle-aged woman ; died of epilepsy.
Obs. 8.* — Marshall Hall method. On turning the body to the
side from the supine posture, 5 cubic inches of air were inspired;
on placing the body prone, with forehead resting on hand, only
2 cubic inches were expelled.
(There is a note to this observation that it is not a satisfac-
tory one.)
Obs. 9. — The plan of rotation, according to Dr. Marshall Hall’s
directions, was now practised several times, with the same gene-
ral result, namely, that about 5 cubic inches of air were inter-
changed by the rotating process; and that 5 additional cubic
inches were expelled by pressure on the back while the body
lay on the abdomen.
Obs. 10. — Dr. Silvester’s method. On elevation of arms, 9
cubic inches of air inspired; on depression of arms, 6 cubic
inches of air expired.
Obs. 11. — The last observation was repeated several times,
and with the average result, that 5 or 6 cubic inches of air were
interchanged.
No pressure on the sternum was practised in these observa-
tions ; they were limited to the effects of simple elevation and
depression of the arms.
Obs. 12. — Pressure on the sternum with the hands, expelled 8
cubic inches of air.
Obs. 13. — Marshall Hall method repeated. Only 2 cubic inches
'j> could now be interchanged.
# Numbered in continuation of last series, the experiments
' being conducted on the same day.
41
Obs. 14. — The same repeated with both arms folded under the
chest ; this arrangement caused an additional expulsion of 4 or
5 cubic inches. /
Obs. 15. — Attempts at inflation of the lungs by a pair of
bellows succeeded in forcing in only 2 cubic inches of air.
The experiments with this body were discontinued.
May 31st, 1862. — At the Marylebone Workhouse.
Subject VI. — An old man ; dead about twenty-four hours ;
emaciated ; died from old age and bronchitis. (The lungs were
examined after the experiments, and found largely infiltrated
with bloody serum, and the smaller bronchi plugged with ropy
mucus.)
Obs. 1. — To determine influence of tongue in impeding en-
trance of air into the lungs.
A. — When the tongue was drawn forward out of the mouth,
and held there by a ligature, air could be readily blown down
the trachea and oesophagus, visibly distending the thoracic and
abdominal cavities.
A a. — Pressure on the larynx interrupted the passage of air
along the oesophagus.
B. — When the tongue was pressed tightly back into the
pharynx entrance of air was prevented, both into the larynx
and oesophagus.
C. — The tongue left loose in the mouth and allowed to fall
back by its own weight, permitted the entrance of air into both
canals, though less freely than in A.
D. — When the head hung back over the table, air seemed to
pass more freely than when it was simply resting on the table.
Obs. 2. — The trachea was now opened and a tube introduced ;
air was blown into the lungs and allowed to escape again, and
the process was repeated several times in imitation of ordinary
respiratory movements. The pressure required to introduce
about the amount of air usually respired was equal to that of a
column of mercury about one-tenth of an inch in height.
Obs. 3. — Dr. Silvester’s method. Head of subject hanging
back over the edge of the table. Only from 4 to 6 cubic inches
of air were interchanged by this method.
Obs. 4. — The method repeated. The head was resting on the
table ; results the same.
Obs. 5. — The method repeated. The head in the same position
as in the last observation, a block placed under the shoulders ;
about one cubic inch more was interchanged.
Obs. 6. — The addition of sternal pressure at the end of the last
observation expelled scarcely any more air.
^ Obs. 7. — Silvester’s method again repeated ; 6 cubic inches of
air were now interchanged. The addition of sternal pressure at
the end of the observation expelled about 5 cubic inches more.
The small amount of air interchanged in these observations led
to the supposition of there being some obstruction either in the
air passages or lung structure, or both. Abundant mixed
crepitations were detected in the lungs during the forced re-
spiratory movements, and gave support to this view; and
examination after the experiments were ended confirmed it.
Nevertheless the observations were continued a little longer.
42
Obs. 8. — Marshall Hall method. On turning the body from
the supine to the lateral posture, 1| cubic inches of air were in-
spired; replaced on the back no air was expelled. When the
body was turned on to the stomach, about 4 cubic inches of air
were expelled. Pressure on the back expelled 1 cubic inch more.
Obs. 9. — The last observation repeated ; amount of air now in-
terchanged was much less.
Obs. 10. — The Silvester method repeated ; scarcely any result,
only 1 or 2 cubic inches of air interchanged.
Obs. 11. — The bronchial tubes were now cleared of much tena-
cious, ropy mucus, by repeatedly sponging them out with a
probang. The Silvester method was then again repeated, but
with the same negative result as in Observation 10. The ex-
periments with this body were accordingly discontinued.
April 17th, 1862. — At St. Bartholomew’s Hospital.
Subject VII, — A youth, set. 17, dead five days from typhus
fever. There was hypostatic discoloration of the lower parts of
the body; the thighs were thickly scattered with petechial spots,
the body was deformed from lateral curvature of the spine.
Obs. 1. — On raising the arms according to Dr. Silvester’s
method, 18-5, 19*5, and 19*5 cubic inches of air were inspired in
three successive movements.
Obs. 2. — On making compression on the sternum, 14*5 cubic
inches of air were expelled, but on relaxing pressure only 11
cubic inches entered the trachea.
Obs. 3. — On repeating the last observation, 12 cubic inches of
air were expelled by compression of the sternum, and 11 cubic
inches re-entered the chest on relaxing the pressure.
Obs. 4. — Repetition of the last observation ; 13 cubic inches of
air were expelled by compression of the sternum; 12 cubic inches
re-entered on relaxing the pressure. The experiment was re-
peated several times, with exactly the same results.
Obs. 5. — On raising the arms, according to Dr. Silvester’s
method, 15 cubic inches of air were inspired. On replacing the
arms to the sides 10 cubic inches were expired. This observation
was repeated several times, with the same result.
Obs. 5 a. — Pressure applied to the sternum after the last Sil-
vester observation expelled 17 cubic inches of air. On with-
drawing the pressure, however, only 11*5 cubic inches of air
were inspired.
Obs. 6. — The arms were again raised, according to the Silvester
method, and compression applied immediately after they had
been brought to the side, with precisely the same results ; and
this process was repeated several times.
Obs. 7. — The body was placed in the prone posture, with the
right arm under the forehead, and the position of the needle
noted. The body was then turned over so as to rest on the
back ; the position of the needle was unaltered. On placing the
body on the side, 2-5 cubic inches of air entered the chest. On
placing the body in the supine posture, the same quantity of ah’
escaped.
Obs. 8. — On placing the body on the left side and a little over,
8 cubic inches of air were inspired. On repeating the prone
posture, 5 cubic inches were expelled.
43
Obs. 9. — The method of Dr. Silvester was then repeated; 11*5
cubic inches of air were inspired on raising the arms ; 11*5 cubic
inches expelled on replacing the arms; 16 additional cubic inches
were expelled on compressing the sternum, yielding a total of
27*5 cubic inches of air expelled from the chest.
General results.
I. As regards the volume of air which can be expelled from
the thorax by compression of its walls, and inspired by the
elastic expansion consequent on relaxation of the pressure, it
was found —
(a) That pressure by both hands on the lower third of the
sternum in the adult male subject usually displaced from 8 to
10 inches of air.
The pressure actually exerted amounted to about 30 lbs. It
was, therefore, not greater than might be safely applied to the
living subject. The volume of air expelled varied from 8 cubic
inches to 15 cubic inches.
(5) That pressure made in the same manner on the upper
part of the sternum usually displaced 2 or 3 cubic inches less
than pressure on the lower part.
(c) That pressure exerted by one hand on the upper part, by
the other on the lower part of the sternum, produced about the
same results as were observed in a.
In this case the whole amount of pressure did not exceed that
exerted in a.
(d) That the pressure of a weight laid on the lower third of
the sternum produced similar results according to its amount.
(e) The lateral pressure exerted on the ribs or costal carti-
lages of both sides simultaneously was in no instance more
effectual.
(/) That compression by a broad bandage encircling the
chest, the ends of which were crossed over the sternum, and
drawn in opposite directions by two persons, produced no
greater effect than pressure with the hands on the sternum or
sides.
II. — The method recommended by the late Dr. Marshall Hall
for imitating respiration was applied to each of the subjects ex-
perimented upon, in accordance with his published instructions.
Sometimes this plan was tried first, before any other method
was employed, sometimes afterwards. It was usually repeated
several times on the same subject, and during the same series
of experiments.
As regards that part of the method which consists in turning
the body alternately “ very gently on the side and a little be-
yond, and then briskly on the face,” it was found that the
volume of air exchanged was variable in the same subject, but
always inconsiderable. It usually happened that a quantity of
air, varying from 1 to 8 cubic inches, never more, generally
much less than 8, was inspired when the body was turned from
the supine posture to one side. When the body was placed on
the abdomen with the head resting on the forearm, a somewhat
larger quantity was expelled, never exceeding 10 cubic inches.
On restoring the body to the lateral posture, the amount of air
44
inspired was usually less than that which had been expelled by
pronation. But the quantity expelled and inspired in each
movement was scarcely ever precisely equal.
The volume of air expelled when the body was placed on the
face was much increased if pressure was at the same time made
on the spine, the amount of this increase varying according to
the degree of the pressure, and in those experiments in which
such pressure was made, it was found that the quantity of air
which was inspired on rotation of the body to the side, was much
less than that which had been expelled by pressure.
As regards the whole amount of exchange of air produced by
the method of Dr. Marshall Hall, “to imitate respiration” it
Varied much according as the subject was favourable, or the
contrary, sometimes not exceeding a few cubic inches, but never
exceeding 15 cubic inches.
III. — As regards the method above described as that of Dr.
Silvester, it was found that, on extending the arms upwards, a
volume of air was inspired into the chest which varied, in dif-
ferent subjects, from 9 to 44 cubic inches ; and it was observed
that the results obtained in successive experiments on the same
body were remarkably uniform, in which respect, as well as in
their quantity or amount, they contrasted with those obtained
by the method of Dr. Marshall Hall. On restoring the arms to
the side, as directed by Dr. Silvester, the quantity of air expelled
was generally nearly equal to that previously inspired, occasion-
ally less.
Dr. Silvester recommends that on bringing down the patient’s
arms they should be gently and firmly pressed against the sides
of the chest, so as to diminish the cavity of the thorax.* It was
found that this pressure could be exercised with greater facility,
and equal effect, by placing the hands on the lower third of the
sternum, as already above described. By alternating the move-
ments of the arms with pressure of this kind, a regular exchange
of air was produced, the quantity of which, in several instances,
exceeded 30 cubic inches, and in one instance amounted to
50 cubic inches. In those cases in which a less respiratory
effect was produced, the deficiency was always distinctly attri-
butable to unfavourable conditions, particularly the existence of
obstructions in the respiratory passages.
Without expressing an opinion as to the efficacy of the method
of Dr. Silvester as a means of restoring suspended animation in
cases of drowning, its claims to be considered as an effectual
means of producing an exchange of air similar to that effected by
the respiratory movements, appear to us to be satisfactorily es-
tablished. As has already been pointed out by Dr. Silvester, the
condition of the thorax after the cessation of breathing being
that of expiration, it is desirable that the first step in the
restoration of breathing should be a movement of expansion ;
in this respect the method he has proposed enjoys a marked
superiority over that of Dr. Marshall Hall, which has for its
object to force air from a chest which has already discharged its
* Vide “ The Physiological Method of Treating Incipient Con -
sumption ” by the author , for further investigations on this subject.
45
natural quantity. It also appears to be an important advantage
in this method, that, in each movement of expansion, both sides
of the chest are left free from compression, and therefore free to
move, while the postural method of Dr. Marshall Hall leaves
only one side free to expand. As regards facility, and readiness
of application, there is also no donbt that the method recom-
mended by Dr. Silvester is at least equally if not more effective
than the Marshall Hall plan.
In the course of the experiments on the dead body certain
facts and observations were recorded not immediately bearing
on the main subjects of inquiry. The principal of these are
stated in the following paragraphs :
Inflation. — A few experiments were performed relating to the
efficiency of the inflation of the lungs through the mouth of the
subject, which led to the conclusion that with proper precau-
tions, such inflation is perfectly practicable. The following
were among the results noticed :
1. As regards the position of the tongue and its influence in
impeding the entrance of air, it was found that in the dead body
this organ is apt to offer great obstruction to inspiration by fall-
ing back into the pharnyx, and closing the laryngeal aperture.
Ho air could be forced through the mouth in a body lying on the
back so long as the tongue remained undisturbed, but when it
was drawn forward and held out of the mouth by a ligature, or
by the pressure of the teeth upon it, air could be injected by the
oesophagus and larynx, so as to distend both the abdominal and
thoracic cavities. On leaving the tongue loose in the mouth,
and allowing it to fall back by its own weight, air could also be
introduced, but much less freely than when it was drawn for-
wards. Complete obstruction to the passage of air was produced
by pressing the tongue back into the pharynx, no air entering
either the larynx or oesophagus.
When the head of the subject was allowed to hang back over
the edge of the table, air seemed to pass into the chest more
readily than when the back of the head rested upon the table.
2. It was found that the whole quantity of air introduced by
inflation could be compelled to enter the respiratory cavity by
pressing back the larynx against the spinal column. By this
expedient the passage of air down the oesophagus was at once
intercepted, while its transit down the trachea continued to take
place as freely as before, so that it affords a ready means of pre-
venting the passage of air into the stomach during artificial
respiration.
3. During inflation of the lungs a sound, closely resembling
that of the ordinary vesicular murmur, is plainly heard, proving
that air enters not merely the larger air passages but the
vesicular structure of the lungs. Marked expiratory murmur
was also heard during the recoil of the lungs and thoracic
parietes after inflation. In cases where the bronchial tubes
were obstructed by secretion, the various kinds of crepitation
could be distinguished.
In the treatment of apnoea generally, the Committee venture
to offer the following suggestions :
46
That all obstruction to the passage of air to and from the
lungs be at once, so far as practicable, removed; that the mouth
and nostrils, for example, be cleansed from all foreign matter or
adhering mucus.
That, in the absence of natural respiration, artificial respira-
tion, by Dr. Silvester’s plan, be forthwith employed in the
following manner The body being laid on its back (either on
a flat surface, or better, on a plane inclined a little from the feet
upwards), a firm cushion, or some similar support, should be
placed under the shoulders, the head being kept on a line with
the trunk. The tongue should be drawn forward so as to pro-
ject a little from the side of the mouth; then the arms should be
drawn upwards until they nearly meet above the head, the
operator grasping them just above the elbows, and then at once
lowered, and replaced at the side. This should be immediately
followed by moderate pressure, with both hands, upon the lower
part of the sternum. This process is to be repeated about
twelve or fourteen times in the minute.
That if no natural respiratory efforts supervene, a dash of hot
water (120° Fahrenheit) or cold water be employed, for the pur-
pose of exciting respiratory efforts.
That the temperature of the body be maintained by friction,
warm blankets, the warm bath, etc.
In the case of drowning, in addition to the foregoing sugges-
tions, the following plan may be, in the first instance, practised :
— Place the body with the face downwards, and hanging a little
over the edge of a table, shutter, or board, raised to an angle of
about 30°, so that the head may be lower than the feet. Open
the mouth and draw the tongue forward ; keep the body in this
position for a few seconds, or a little longer if fluid continues to
escape. The escape of fluid may be assisted by pressing once or
twice upon the back.
It will be seen that these investigations relate only to two
forms of apnoea — that produced by the simplest means, apnoea
in its least complicated form, and that produced by drowning.
It was found to be utterly impracticable, in the time allotted, to
extend our inquiries to other forms of apnoea. Indeed, even
within these limits, the Committee have found it necessary to
disregard many collateral questions of great interest, and to
confine their attention to the chief features of the subject.
C. J. B. Williams, Chairman.
W. S. Kirkes,
George Harley,
J. B. Sanderson,
C. E. Brown-Sequard,
H. Hyde Salter,
William S. Savory, Eon. Sec.
E. H. Sieveking,
Hon. Sec. Med. Chir. Soc. (ex-officio)
T. RICHARDS, 37, GREAT QUEEN STREET.
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